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中华妇幼临床医学杂志(电子版) ›› 2023, Vol. 19 ›› Issue (03) : 287 -294. doi: 10.3877/cma.j.issn.1673-5250.2023.03.007

论著

影响2次剖宫产术后阴道试产产妇试产成功因素及妊娠结局分析
陈莉1, 雷雪芹2, 段炼1, 曾悦1, 何国琳1,†()   
  1. 1四川大学华西第二医院产科、出生缺陷与相关妇儿疾病教育部重点实验室，成都　610041
    2四川省凉山彝族自治州雷波县人民医院，雷波　616550
  • 收稿日期:2022-09-15 修回日期:2023-04-10 出版日期:2023-06-01
  • 通信作者: 何国琳

Analysis of influencing factors of success of trial of labor after twice cesarean sections and its pregnancy outcomes

Li Chen1, Xueqin Lei2, Lian Duan1, Yue Zeng1, Guolin He1,†()   

  1. 1Department of Obstetrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
    2Leibo County People′s Hospital of Liangshan Yi Autonomous Prefecture, Leibo 616550, Sichuan Province, China
  • Received:2022-09-15 Revised:2023-04-10 Published:2023-06-01
  • Corresponding author: Guolin He
  • Supported by:
    Key Special Project of National " 14th Five-Year Plan" Key Research and Development Program(2021YFC2701501)
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引用本文：

陈莉, 雷雪芹, 段炼, 曾悦, 何国琳. 影响2次剖宫产术后阴道试产产妇试产成功因素及妊娠结局分析[J/OL]. 中华妇幼临床医学杂志(电子版), 2023, 19(03): 287-294.

Li Chen, Xueqin Lei, Lian Duan, Yue Zeng, Guolin He. Analysis of influencing factors of success of trial of labor after twice cesarean sections and its pregnancy outcomes[J/OL]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2023, 19(03): 287-294.

目的

探讨2次剖宫产术后阴道试产(TOLAC-2)产妇妊娠结局，以及影响TOLAC-2成功因素。

方法

选择2016年1月至2021年8月凉山彝族自治州雷波县人民医院收治的既往有2次剖宫产术分娩史、本次妊娠自愿选择TOLAC-2的53例产妇为研究对象。采取回顾性分析方法，按照产妇最终分娩方式，将其分别纳入成功组(n＝31，TOLAC-2成功者)与失败组(n＝22，TOLAC-2失败后中转剖宫产术分娩者)。采用成组t检验、Mann-Whitney U检验、χ2检验、连续性校正χ2检验或Fisher确切概率法，比较2组产妇住院时间、费用与抗菌药物治疗时间及母婴结局等。分析失败组产妇TOLAC-2失败原因。本研究遵循的程序符合宜宾市第二人民医院伦理委员会规定，并通过该伦理委员会审查及批准(审批文号：2022-015-01)。2组产妇的年龄、分娩孕龄、前次分娩新生儿出生体重、本次分娩前超声预估胎儿体重、家庭人均年收入、学历等一般临床资料分别比较，差异均无统计学意义(P>0.05)。

结果

①影响成功组与失败组产妇试产成功因素的单因素分析结果显示，成功组产妇孕期体重增加值、分娩前人体质量指数(BMI)分别为(13.4±5.2) kg、(27.0±3.2) kg/m2，均显著低于失败组的(15.6±5.8) kg、(28.4±3.0) kg/m2，并且差异均有统计学意义(t＝－2.78、－2.91，P＝0.006、0.004)。2组产妇孕前BMI、阴道分娩史、本次妊娠距前次剖宫产术分娩间隔时间、产后出血(PPH)史、坐骨结节间径、分娩镇痛方式与妊娠期糖尿病、妊娠期高血压疾病发生率，新生儿出生体重等分别比较，差异均无统计学意义(P>0.05)。②成功组产妇抗菌药物治疗时间、住院时间、住院费用，均显著短于或低于失败组，并且差异均有统计学意义(t＝－4.05、－5.71、－8.97，P＝0.004、<0.001、<0.001)。2组产妇TOLAC-2时不全性子宫破裂、完全性子宫破裂、PPH、严重PPH、输血治疗、宫内感染发生率，以及产后2 h与24 h出血量，新生儿生后1 min Apgar评分、窒息率、病理性黄疸率、转入新生儿重症监护病房(NICU)率等母婴结局分别比较，差异均无统计学意义(P>0.05)。③失败组22例产妇TOLAC-2失败前3位原因依次为：产妇中途放弃TOLAC-2(10例，45.5%)，胎儿宫内窘迫(5例，22.7%)与产程停滞(5例，22.7%)。

结论

孕期体重增加值、分娩前BMI是影响TOLAC-2产妇阴道分娩试产成功因素。TOLAC-2产妇试产成功，有助于缩短2次剖宫产术后再次妊娠者的住院时间与抗菌药物治疗时间，降低住院费用，同时并未增加母婴严重不良结局发生率。

关键词: 剖宫产后阴道分娩, 剖宫产术，再, 2次剖宫产术后阴道试产, 妊娠结局, 子宫破裂, 产后出血, 产妇
Objective

To investigate the pregnancy outcomes of pregnant women with a history of trial of labor after twice cesarean sections (TOLAC-2) and influencing factors of success of TOLAC-2.

Methods

Fifty-three pregnant women with twice prior cesarean sections and voluntarily chose TOLAC-2 in the Leibo County People′s Hospital of Liangshan Yi Autonomous Prefecture from January 2016 to August 2021 were selected as research subjects. They were included into successful group (n=31, succeeded in TOLAC-2) and failed group (n=22, by repeated cesarean section after failure of TOLAC-2) according to the final model of delivery. Maternal length of hospital stay, cost of hospitalization, duration of antibacterial drug therapy, maternal and infant outcomes were compared between two groups with independent-samples t test, Mann-Whitney U test, chi-square test, continuity correction of chi-square test or Fisher′s exact probability test. Maternal factors that contributed to TOLAC-2 failure in failed group were analyzed. The procedures in this study were in accordance with the regulations of the Yibin Second People′s Hospital, and this study was approved by the Ethics Committee (Approval No. 2022-015-01). There were no statistical differences between two groups in general clinical data, such as maternal age, gestational age at delivery, neonatal birth weight of previous delivery, percapita annual income in family and education background (P>0.05).

Results

①Results of one-way analysis of influencing factors of success of trial of labor in successful group and failed group showed that maternal weight gain during pregnancy and body mass index (BMI) before delivery in successful group were (13.4±5.2) kg and (27.0±3.2) kg/m2 respectively, which both were significantly lower than those (15.6±5.8) kg, (28.4±3.0) kg/m2 in failed group, and both the differences were statistically significant (t=-2.78, -2.91; P=0.006, 0.004). There were no statistical differences between two groups in maternal BMI before pregnancy, history of vaginal delivery, interval time between this delivery and last cesarean delivery, history of postpartum hemorrhage (PPH), ischial intertuberal diameter, method of labor analgesia, incidence of gestational diabetes mellitus, incidence of hypertensive disorder complicating pregnancy and neonatal birth weight (P>0.05). ②Duration of maternal antibacterial drug therapy, length of hospital stay, and hospital costs in successful group were significantly shorter or lower than those in failed group (t=-4.05, -5.71, -8.97; P=0.004, <0.001, <0.001). There were no statistical differences between two groups in maternal and neonatal outcomes, such as incidence of incomplete uterine rupture, complete uterine rupture, PPH, severe PPH, blood transfusion therapy, and intrauterine infection during TOLAC-2, volume of 2 h PPH, volume of 24 h PPH, and neonatal Apgar score 1 min after birth, incidence of neonatal asphyxia, neonatal pathological jaundice, and admission to neonatal intensive care unit (NICU) (P>0.05). ③The top 3 reasons for TOLAC-2 failure in failed group were maternal abandonment of TOLAC-2 midway (10 cases, 45.5%), intrauterine asphyxia (5 cases, 22.7%) and arrested labor (5 cases, 22.7%) in turn.

Conclusions

Weight gain during pregnancy and BMI before delivery are influencing factors of success of trial of labor in TOLAC-2 pregnant women. The success of TOLAC-2 can shorten the length of hospital stay and duration of antibacterial drug therapy in pregnant women with twice prior caesarean sections, reduce cost of hospitalization and do not increase the incidence of serious adverse maternal and neonatal outcomes at the same time.

Key words: Vaginal birth after cesarean, Cesarean section, repeat, Trial of labor after twice cesarean sections, Pregnancy outcome, Uterine rupture, Postpartum hemorrhage, Puerpera
表1 2组TOLAC-2产妇一般临床资料比较
组别 例数 年龄(岁，±s) 分娩孕龄(周，±s) 新生儿出生体重(g，±s) 人均年收入a[例数(%)] 受教育程度[例数(%)]
前次 本次预估 ≤15 000元 >15 000元 大专及以上 高中及以下
成功组 31 28.1±6.2 38.8±2.3 3 390±300 3 229±747 2(6.5) 29(93.5) 5(16.1) 26(83.9)
失败组 22 30.1±6.8 38.7±2.7 3 450±850 3 325±666 3(13.6) 19(86.4) 2(9.1) 20(90.9)
统计量   t＝－1.12 t＝0.09 t＝－1.41 t＝－0.68 χ2＝0.16b χ2＝0.11b
P值   0.266 0.928 0.160 0.423 0.689 0.740
表2 影响成功组与失败组产妇试产成功因素的单因素分析
组别 例数 孕前BMI(kg/m2，±s) 孕期体重增加值(kg，±s) 分娩前BMI(kg/m2，±s) 阴道分娩史[例数(%)] 分娩间隔时间[月，M(Q1，Q3)] PPH史[例数(%)]
成功组 31 22.0±6.4 13.4±5.2 27.0±3.2 2(6.5) 56.4(35.5，86.0) 3(9.7)
失败组 22 22.6±6.2 15.6±5.8 28.4±3.0 2(9.1) 71.9(41.0，111.0) 2(9.1)
统计量   t＝－1.25 t＝－2.78 t＝－2.91 χ2＝0.03a Z＝－2.20 χ2＝0.16a
P值   0.213 0.006 0.004 0.862 0.067 0.689
组别 例数 坐骨结节间径[cm，M(Q1，Q3)] 分娩镇痛[例数(%)] 妊娠期糖尿病[例数(%)] 妊娠期高血压疾病[例数(%)] 新生儿出生体重(g，±s)
成功组 31 9.1(8.5，10.0) 15(48.4) 10(32.3) 4(12.9) 3 029±747
失败组 22 8.5(8.0，9.0) 10(45.5) 7(31.8) 2(9.1) 3 125±666
统计量   Z＝－7.10 χ2＝0.04 χ2<0.01 χ2<0.01a t＝－0.48
P值   0.135 0.833 0.975 0.973 0.633
表3 成功组与失败组母婴结局比较
组别 例数 子宫破裂[例数(%)] PPH[例数(%)] 严重PPH[例数(%)] 输血治疗[例数(%)] 胎盘早剥[例数(%)] 宫内感染[例数(%)] 产后2 h出血量[mL，M(Q1，Q3)]
不全性 完全性
成功组 31 1(3.2) 0(0) 9(29.0) 2(6.5) 2(6.5) 2(6.5) 1(3.2) 312.5(213.7，523.4)
失败组 22 1(4.5) 1(4.5) 6(27.3) 1(4.5) 1(4.5) 1(4.5) 2(9.1) 409.8(322.5，453.8)
统计量   —a —a χ2＝0.02b χ2＝0.09b χ2＝0.09b χ2＝0.09b χ2＝0.09b Z＝－1.18
P值   0.490 0.420 0.889 0.767 0.767 0.767 0.767 0.236
组别 例数 产后24 h出血量[mL，M(Q1，Q3)] 产妇抗菌药物治疗时间(h，±s) 1 min Apgar评分(分，±s) 新生儿窒息[例数(%)] 新生儿黄疸[例数(%)] 转入NICU[例数(%)] 住院时间(d，±s) 住院费用(元，±s)
成功组 31 390.1(301.2，560.1) 9.6±12.4 8.4±1.6 5(16.1) 3(9.7) 4(12.9) 3.2±0.9 2 133±260
失败组 22 425.5(338.3，465.5) 35.3±12.6 7.3±2.6 5(22.7) 4(18.2) 5(22.7) 4.5±0.7 6 718±662
统计量   Z＝－0.26 t＝－4.05 t＝1.90 χ2＝0.06b χ2＝0.24b χ2＝0.32b t＝－5.71 t＝－8.97
P值   0.793 0.004 0.063 0.806 0.624 0.572 <0.001 <0.001
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